A Look at Access to Health Services and the Intersection of Immigration Status with Medicaid and Insurance Eligibility

July 05, 2018|2:39 p.m.| ASTHO Staff

Noncitizens in the United States make up about seven percent of the total U.S. population and are more likely to be low-income and uninsured than citizens. Census data estimates that 71 percent of undocumented adult noncitizens do not have health insurance. Federally Qualified Health Centers (FQHCs) and select public health programs serve immigrants regardless of their immigration status. Medicaid, the publicly funded health insurance program for lower-income Americans, limits eligibility for immigrants to those qualified immigrants with refugee status or those who are veterans and those who have been lawfully present in the United States for five years. States can choose whether to provide coverage to legally present immigrants before their five-year waiting period expires.

The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (often referred to as PRWORA or welfare reform) created the qualified immigrant standard for Medicaid: refugees and asylum seekers are eligible for Medicaid and all other lawfully present immigrants must wait five years before they can be considered eligible. As a result of PRWORA, other safety net programs such as Temporary Assistance for Needy Families (TANF), the Supplemental Nutrition Assistance Program (SNAP), and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), also apply the five-year waiting period for legally present immigrants.

Since 2009, states have been able to get matching funds from Medicaid for choosing to provide Medicaid coverage to legally present immigrants who are children or pregnant women before the end of the five-year waiting period. Presently, 33 states have elected to cover lawfully residing immigrant children, and 25 states that largely overlap with those 33 have also chosen to cover legally present pregnant women. Although the Affordable Care Act (ACA) made Medicaid coverage for adults with incomes up to 138 percent of the Federal Poverty Level an option for states, it left the five-year waiting period for legally present immigrants intact. However, ACA made it possible for legally present immigrants, who are ineligible for Medicaid due to being in the five-year waiting period, to qualify for commercial coverage and subsidies that are available only on the marketplace.

Many states have created their own programs to supplement health and human services benefits available for immigrants. While this approach has afforded states the opportunity to develop programs based on their unique priorities, it has resulted in a complex benefits landscape that differs from state to state. For example, California is poised to expand Medicaid to all noncitizens, regardless of immigration status: an estimated 1.2 million undocumented immigrants could qualify for Medicaid, with cost estimates to expand it to poor adult immigrants projected at $3 billion annually. Oregon also enacted legislation in 2017 expanding access to more than 17,000 immigrant children. In addition, states have created programs to provide cash assistance through the state-funded TANF replacement programs and state-only food assistance for those not eligible for SNAP, though these vary greatly with respect to eligibility. Five states provide state-funded nutrition assistance to some immigrants who were ineligible for the federal SNAP program.

Even for immigrants who are eligible for Medicaid or employer-sponsored insurance, other barriers to care exist. For those speaking English as a second language, navigating a complex health delivery system is daunting. Moreover, immigration officials, when reviewing case files, consider the likelihood of individuals and families becoming a “public charge,” which can result in denied admission to the United States or status as a lawful permanent resident. As a result, fear that using safety net services will mean being considered a public charge contributes to some families of mixed immigration status avoiding use of those services. Additionally, some eligible immigrants avoid services for fear that family members will become involved in immigration enforcement actions. In December 2017, Kaiser Family Foundation’s research findings included reported changes in healthcare use and decreased participation in Medicaid and the Children’s Health Insurance Program as a result of immigration policy. Another major finding of the focus groups was reported fears around immigration policy leading families to experience increased levels of toxic stress. Avoiding care for one or a combination of factors translates into greater medical costs for the individual and the state when complications from untreated illness, injury, or chronic conditions escalate.

Local health departments and FQHCs have traditionally been sources of healthcare for low-income immigrants. These providers can improve quality of care and health outcomes for immigrants regardless of status by implementing best practices. In addition, they can even increase revenue to the provider by connecting eligible noncitizens to affordable care options that reimburse for care. State and territorial health officials, as the chief health strategists in their states, should understand both the eligibility limitations and other access barriers immigrant populations face. Increased awareness of the position local health departments and FQHCs play in serving immigrant populations can help inform choices around funding and programming for service delivery.